Intensive Care Med (2009) 35:397–404

DOI 10.1007/s00134-008-1255-9 REVIEW

Claas T. Buschmann
Michael Tsokos
Frequent and rare complications
of resuscitation attempts

Received: 8 January 2008
Accepted: 7 August 2008
Published online: 20 September 2008
Ó Springer-Verlag 2008
C. T. Buschmann ())
M. Tsokos
University Medical Centre Charité,
University of Berlin, Institute of Legal
Medicine and Forensic Sciences, Turmstr.
21, Building L, 10559 Berlin, Germany
e-mail: claas.buschmann@charite.de
Tel.: ?49-30-901728147
Fax: ?49-30-901728154
URL: http://remed.charite.de/
Abstract Introduction: Resuscita-
tion attempts require invasive
iatrogenic manipulations on the
patient. On the one hand, these mea-
sures are essential for survival, but on
the other hand can damage the patient
and thus contain a significant viola-
tion risk of both medical and forensic
relevance for the patient and the
physician. We differentiate between
frequent and rare resuscitation-related
injuries. Factors of influence are
duration and intensity of the resusci-
tation attempts, sex and age of the
patient as well as an anticoagulant
medication. Materials and methods:
Review of current literature and
report on autopsy cases from our
institute (approximately 1,000 autop-
sies per year). Results: Frequent
findings are lesions of tracheal struc-
tures and bony chest fractures. Rare
injuries are lesions of pleura, peri-
cardium, myocardium and other
internal organs as well as vessels,
intubation-related damages of neural
and cartilaginous structures in the
larynx and perforations of abdominal
organs such as liver, stomach and
spleen. Conclusion: We differenti-
ate between frequent and rare
complications. The risk of iatrogenic
CPR-related trauma is even present
with adequate execution of CPR
measures and should not question the
employment of proven medical
techniques.
Keywords Resuscitation-related
injuries
Frequencies
Medical
relevance
Forensic relevance

Introduction In the following, we report on cases from literature as

well as on autopsy cases from our institute (approximately
Resuscitation measures such as external cardiac mas- 1,000 autopsies per year are performed here) in which
sage [cardiopulmonary resuscitation, (CPR)], external resuscitation-related trauma caused by iatrogenic manip-
defibrillation, endotracheal intubation and cannulation ulations became obvious during autopsy.
of peripheral and central vessels for the application of
drugs have been performed for a long time in patients
with cardiopulmonary arrest and uncertain death signs
until either a sufficient spontaneous circulation is Frequent complications
achieved or the definitive death of the patient is stated Neck
[16]. These necessary, potentially life-saving emergency
measures contain a significant violation risk of both Besides the chest wall, airways are often affected by
medical and forensic relevance for the patient and the iatrogenic resuscitation trauma—reclination of the head
physician. for manual artificial respiration as well as endotracheal
398
Fig. 1 Substantial hematoma in the neck musculature and soft
parts (arrows), caused by repeated intubation attempts and
hyperextension of the head. Resuscitation of a patient undergoing Fig. 3 Rib fracture (square) after external CPR
phenprocoumon therapy
intubation can be considered as external blunt injuries.
Frequent consequences of resuscitation attempts (9.2%)
are retropharyngeal bleedings. Apart from tooth damage,
(tracheal) mucosa lesions caused by multiple intubation
attempts are frequently observed resuscitation-related
injuries (18%) [10, 19]. In an autopsy case from our
institute, a massive hematoma in larynx and pharynx
was caused by unsuccessful, repeated intubation efforts
and hyperextension of the head when artificially respi-
rating a patient who was anticoagulated with
Phenprocoumon. The inner neck hematoma after futile
resuscitation caused petechial bleedings in the conjunc-
tivas and a vena cava superior syndrome, which at first
appeared to be death by strangling (Fig. 1). During
autopsy, cause of death was found to be an acute
myocardial infarction.
Fig. 2 Sternal fracture (square) after external CPR
Chest
In connection with resuscitation measures, the most fre-
quent bony injuries which can be observed are rib and
sternal fractures caused by external CPR with 13–97% of
cases, depending on literature (Figs. 2, 3) [5, 9]. Rib
fractures are more often situated on the left side (second–
seventh rib) than on the right side (second–sixth rib) of
the chest wall in the medial clavicle line and are wide-
spread in older patients, as for chest compression
increased energy expenditure is necessary because of
increased chest wall rigidity [5]. In addition, with higher
age the risk of underlying osteopenia is increased,
especially in females [37]. These injuries must be dis-
tinguished forensically from other causes of chest wall
trauma, for example attack or accident [33]. Remarkable
in this context is the fact that conventional X-ray exam-
inations have limitations when it comes to diagnosing
bony thorax injuries; these injuries are often only con-
firmed by autopsy [18].
Resuscitation-related injuries of the thorax wall are
rarely observed in children; on the one hand, the infantile
chest is of higher elasticity than in older people, on the
other hand resuscitation measures are altogether rarer
during infancy. If infantile bony injuries are present, they
must be differentiated from trauma caused by repetitive
child abuse and/or battering [25]. It appears complicating
that in rare cases, well-known abuse-related injuries like
retinal bleedings or rib fractures may be provoked by
resuscitation attempts in infants [3, 24]. As well as in
adults, increasing duration of resuscitation measures rai-
ses the probability to provoke serious injuries of the bony
chest in children [28].
After external cardiac defibrillation, energy passing
through the chest wall may cause temporary skin eryth-
emas in case that the defibrillation electrodes have direct
contact with the skin, not being separated from the skin
surface by a protecting but current-conducting gel layer
(80% of cases); this erythema usually heals after
 399

successful resuscitation [1] without forensic relevance.
Bony chest injuries can be connected with further
superficial skin lesions caused by external CPR in the
sternal area. Dermabrasiones are very often found after
resuscitation measures and are usually without forensic
relevance, but may hint to underlying bone lesions of the
chest wall. We observed sternal dermabrasio combined
with solid iatrogenic serial rib fractures as well as sternal
fractures in the case of a fatal aortic dissection with
following pericardial tamponade; with pericardial tam-
ponade, the rescue team was unable to generate sufficient
blood circulation. Thus, external CPR was performed
with increased energy expenditure, which caused, apart
from skin lesions, pronounced bony chest injuries.
myocardium, pericardium, pleura, diaphragm or pneumo-
and/or hematothoraces, success of resuscitation measures
is affected negatively [32]. Bode and Joachim [4] describe
cases of aortic ruptures from CPR, particularly located in
the Pars descendens, and give the incidence of 1%.
According to literature findings, these complications are
rare and arise more frequently if external CPR is per-
formed with active compression–decompression devices
like the Cardio PumpÒ [26]. Aspiration of stomach con-
tents may be evoked if external CPR is performed with
substantial energy expenditure [17].
Abdomen

Naturally, visceral structures are less affected from

Abridged resuscitation-related trauma than thoracic structures as
mechanical resuscitation attempts focus primarily on heart
Frequent findings after unsuccessful CPR in the upper and chest—however, upper belly organs such as liver,
airways are above all lesions of tracheal structures caused stomach and spleen might be injured due to the topo-
by protracted intubation attempts. In the thoracal region, graphic conditions [12, 20, 23]. Injuries of visceral
rib and sternal fractures are often caused by external CPR, structures are mainly based on fractured ribs and/or the
while perforations of abdominal organs can be due to sternal bone—with external CPR exerted forces being
gastric air insufflations after tracheal false intubation. transferred through the unstable thorax to the visceral
organs, which may lead to ruptures and perforations. Due
to the anatomical situation, the left liver lobe is mainly
affected; Meron and colleagues report in an autopsy series
on liver lesions in 0.6% of all cases, while spleen or gastric
Rare and very rare complications
affections were even rarer. An inadequately performed
Neck CPR is regarded as a main factor for resuscitation-related
visceral injuries [20, 35]. Krischer et al. [15] reported on
Rare injuries within the neck area after resuscitation injuries of the liver in 2.1% of cases (Figs. 4, 5). Spleen or
attempts are lesions of the recurrent nerves, the sinus pir- gastric ruptures are still rarer. In case of stomach lesions,
iformis, the vocal cords and the arytenoids’ cartilages, the incidence is indicated with 1% [6]; however, not only
which result from mechanical manipulations connected
with endotracheal intubation [5]. Lacerations of the intima
of the carotids have been observed as a result of mechanical
tractive forces during hyperextension of the head [29].
Life-saving emergency measures like tracheotomy or
coniotomy may cause further complications [2]. Depend-
ing on the size of the incision, mucous membrane lesions
and expanded bleedings with aspiration and transfer of
blood to the respiratory system have been described. Since
performance of tracheotomy and coniotomy—due to the
described complications—has decreased in today’s pre-
clinical routine, the smaller portion of the autopsy-con-
firmed resuscitation-related injuries of the cervical region
is accompanied by stricter indication position.

Chest

Cases of rhabdomyolysis and myoglobinuric renal failure

after external defibrillation and cardioversion have
been reported but seem to be quite rare events [22]. If
fractured ribs cause a pericardial tamponade, injuries of Fig. 4 Hepatic rupture (square) after CPR
400
Fig. 5 Subcapsular hematoma of the liver (square) after CPR
Fig. 6 Air-filled stomach after false intubation
mechanical conditions, but also artificial respiration with
high-pressure ratios are made responsible here.
Incorrect intubation of the trachea—the endotracheal
tube is placed in the esophagus—may lead to gastric
overstretching due to continuous air insufflation into the
stomach (Fig. 6), in the worst case followed by gastric
rupture, hemato- and pneumoperitoneum (Fig. 7) if
undiscovered [6, 7, 14, 21, 30]. Gastric rupture during
CPR is a relatively rare event. Fewer than 30 cases have
been reported in the English-language literature during
the past two decades [34]. With ongoing CPR, the risk of
provoking a gastric perforation or rupture increases as the
stomach then will be compressed at the same time from
the inside by air and from the outside by external CPR.
Altogether, false intubations are easier to detect than
visceral perforations by fractured bones with following
bleeding into the abdominal cavity, since false intubations
quickly present clinical indications such as cyanosis and
curvature of the abdomen. These situations are easy to
Fig. 7 Gastric rupture (square) after false intubation
recognize and immediately remediable by replacing the
ventilation tube into the trachea. We suppose that false
intubation may occur frequently, but is corrected during
resuscitation measures. Thus, evidence of false intubation
in forensic routine is seldom found.
Visceral traumas after resuscitation attempts are rare,
but serious and under ongoing resuscitation, they cannot
be treated, contrary to inadvertent intubations of the tra-
chea. Free fluid in the abdominal cavity, particularly with
two-stage bleeding, may appear with latency intervals.
Becoming symptomatic with hemodynamic instability,
abdominal bleedings require immediate surgery if resus-
citation measures are successful. Altogether, clinical
proceedings are complicated by visceral bleedings [40].
Discovering abdominal bleedings due to resuscitation
measures is difficult as circulation depressions are usual
findings in patients under resuscitation [20]. Furthermore,
emergency physicians may perform a thrombolytic
treatment since acute myocardial infarction is an assumed
frequent cause of cardiac arrest. Thrombolytic treatment
increases the risk of bleeding complications to up to
10%—especially if patients are already anticoagulated. It
seems that the duration of resuscitation measures has no
influence on the occurrence of visceral bleedings [13].
Figure 8 shows a human bony skeleton annotated with
percentages of injury frequencies.
Further injuries
A further rare, but dangerous complication is iatrogeni-
cally provoked air embolism after cannulation of the
external jugular vein. This vessel is frequently cannulated
in resuscitation attempts, as it is located at the exterior of
the neck and thus easily accessible for the physician who
usually works at the head of the patient. With sufficient
external CPR, (physiologic) negative pressure can be
 401

Fig. 8 Human bony skeleton,

annotated with percentages of
injury frequencies

produced in this vessel and ambient air may be sucked Table 1 Resuscitation-related injuries, percentage of occurrence
into the venous system of the head. Also, pulmonary with reference to the literature
barotrauma caused by intubation and artificial respiration
Injury pattern Percentage of Reference
may provoke cerebral air embolism [31, 39]. occurrence no.

Resuscitation-related injuries 21.0–65.0 [8]

Abridged Frequent complications
(Temporary) skin erythema 80.0 [1]
Besides conio- or tracheotomy-induced complications, Rib fractures in adults 13.0–97.0 [5, 9]
Sternal fractures 1.0–43.0 [5, 9]
rare post-resuscitation neck injuries are intubation-related Tracheal lesions 18.0 [10]
damages of neural and cartilaginous structures in the lar- Retropharyngeal bleedings 9.2 [19]
ynx. Rare chest injuries are lesions of pleura, pericardium, (Very) rare complications
myocardium and other internal organs as well as vessels, Liver injuries 0.6–2.1 [15, 20]
Rib fractures in children 0.0–2.0 [9]
caused by fractured ribs, while within the abdomen pri- Aortic ruptures 1.0 [4]
marily liver, stomach and spleen are affected by Stomach lesions (excl gastric rupture) 1.0 [6]
inadequately performed CPR and incorrect pressure ratios. Gastric rupture \1.0 [27]
Table 1 gives an overview on the different injury Post-defibrillation rhabdomyolysis \1.0 [22]
Spleen lesions \1.0 [15]
patterns and their frequency of occurrence according to Air embolism \1.0 [31, 38]
the literature.

Discussion external defibrillation, endotracheal intubation and can-

nulation of peripheral and central vessels for the
Medical aspects application of drugs. These measures are essential for
successful resuscitation, but may damage the patient’s
Resuscitation attempts require invasive iatrogenic health. The total incidence of resuscitation-related injuries
manipulations on the patient such as external CPR, is indicated altogether with 21–65% [8].
402
The successful execution of CPR requires the
knowledge of topographic and anatomical conditions, the
applied techniques and their specific risks. Thus, among
emergency medical professionals the question is raised
whether the avoidance of serial rib fractures is to be
settled higher than the acceptance of a smaller mechan-
ical effect on the heart by performing CPR with smaller
energy expenditure.
The guidelines to CPR of the European Resuscitation
Council of 2005 recommend a compression depth of 4–
5 cm with a compression frequency of 100/min to ensure
an effective arterial blood flow. Moreover, the value of a
sufficient thorax compression is emphasized in relation to
breath donation, since 80% of cardiopulmonary arrests
are based cardiacally and arterial oxygen content is still
sufficiently high in the first minutes after cardiopulmo-
nary arrest [11]. This can be interpreted in such a manner
that—in particular with a rigid thorax—a sufficient effect
of CPR is only enabled if rib or sternal fractures are taken
in purchase. Altogether, complication rates are lower and
outcome is higher if CPR measures are executed
according to guidelines. This mainly applies if thorax
compression—even in the first minutes after cardiac
arrest—is not interrupted [36, 38].
We remark that rib and sternal fractures often occur
after successful CPR (Lederer and colleagues [18] give a
frequency of 94.7%), but rarely affect the patient’s out-
come after resuscitation negatively. On the other hand,
sternal or rib fractures can cause pneumo- and/or hemat-
othoraces and/or lung injuries, so that secondarily
respiration disturbances in the post-resuscitation phase
may occur frequently, containing the long-term risk of
lethal complications such as the ‘‘Adult Respiratory Dis-
tress Syndrome’’ (ARDS) [4]. Thus, iatrogenically induced
traumata are not only of high significance pre-clinically
while performing CPR, but also injuries can become evi-
dent in the hospital after successful stabilization, e.g.,
splenic two-stage bleeding or covered organ perforations.
It is more important to further consider the means and
circumstances and to seize measures which on the one
hand minimize the risk of immediate complications and
on the other hand save the patient from damage in the
further process. The placement of a gastric tube may be
performed, e.g., for pressure relief and aspiration pro-
phylaxis; an iatrogenically induced complication can be
the aspiration of stomach contents [17] or gastric rupture
after artificial respiration with high pressure ratios, usu-
ally located in the small curvature [4, 27].
Forensic aspects
From our own practice, we do not know of any case in
which solely an iatrogenic induced CPR injury would have
entailed legal consequences. Scenarios—also in connec-
tion with CPR measures—which involve legal
Table 2 Possible post-resuscitation injury complications
Injury Pattern Possible post-resuscitation
injury complications
(Temporary) skin erythema None
Defibrillation Rhabdomyolysis
Rib-/sternal fractures Hemato- and pneumothorax,
traumatic lesions of heart, lungs
and upper belly organs
Tracheal lesions Pneumomediastinum, hypoxemia
Retropharyngeal bleedings Vena cava superior syndrome
Liver and spleen injuries, Hemorrhagic shock, exsanguination
aortic ruptures
Stomach lesions Pneumoperitoneum
Air embolism Apoplectic insult
consequences for the physician after obviously wrong
treatment of the patient, for example false intubations of the
trachea, are conceivable, of course. However, it is negligent
to miss necessary CPR measures to prevent oneself from
prosecution. Forensic relevance also exists in omitting CPR
attempts without safe death signs being present. From the
medicolegal point of view, complications and accidental
iatrogenic injuries will never be completely avoidable but
their possibility has to be taken into consideration
throughout further medical treatment. Beside physicians,
medical assistance personnel such as nurses and paramed-
ics are concerned. For forensic pathologists, forensic
relevance lies in the secure, autopsy-confirmed differenti-
ation between CPR-related and other injury causes.
Consequences for hospitals and practice
Resuscitation-related injuries cannot be avoided and will
appear inevitably with increasing duration of resuscitation
attempts, particularly if some factors are added; factors of
influence are duration and intensity of the resuscitation
measures, sex and age of the patient as well as an anti-
coagulant medication. Furthermore, these injuries are
often not conspicuous immediately, but manifest them-
selves rather by missing success of CPR measures. Thus, a
diagnostic consideration of the physicians must be to look
for iatrogenic injuries if the condition of a patient under
CPR cannot be stabilized and no causes are recognizable
which let the success of CPR measures appear improbable
(e.g., traumatic genesis with hemorrhagic shock after blunt
trauma [5]) and/or these factors can be treated causally.
Conclusions
In connection with CPR, we differentiate between fre-
quent and rare complications. The spectrum of possible
complications following resuscitation measures is given
in Table 2. The risk of iatrogenic CPR-related trauma is

even present with adequate execution of CPR measures
and should not question the employment of proven
medical techniques.
Forensic scientists as well as clinical practitioners
should know about the relevance and frequency of the
occurrence of iatrogenically induced resuscitation injuries
References
1. Alconero Camarero AR, Casaus Pérez
M, Gutiérrez Caloca N (2006) Incidents
of cutaneous alteration secondary to
external electrical cardioversion.
Enferm Intensiva 17:163–172
2. Bauer H, Welsch K (1976) Punktions-
Techniken in der Notfallmedizin.
Münchener Medizinische
Wochenschrift 118:567–572
3. Betz P, Liebhardt E (1994) Rib
fractures in children—resuscitation or
child abuse? Int J Legal Med 106:215–
218
4. Bode G, Joachim H (1987) Zur
Differentialdiagnose von Unfall- und
Reanimationstraumen. Z Rechtsmed
98:19–32
5. Darok M (2004) Injuries resulting from
resuscitation procedures. In: Tsokos M
(ed) Forensic pathology reviews Vol 1.
Humana Press Inc, Totowa NJ, pp 293–
303
6. Eldor J, Ofek B, Abramowitz HB
(1990) Perforation of oesophagus by
tracheal tube during resuscitation.
Anaesthesia 45:70–71
7. Hartoko TJ, Demey HE, Rogers PE,
Decoster HL, Nagler JM, Bossaert LL
(1991) Pneumoperitoneum—a rare
complication of cardiopulmonary
resuscitation. Acta Anaesth Scand
35:235–237
8. Hashimoto Y, Moriya F, Furumiya J
(2007) Forensic aspects of
complications resulting from
cardiopulmonary resuscitation. Leg
Med 9:94–99
9. Hoke RS, Chamberlain D (2004)
Skeletal chest injuries secondary to
cardiopulmonary resuscitation.
Resuscitation 63:327–338
10. Jaeger K, Ruschulte H, Osthaus A,
Scheinichen S, Heine J (2000) Tracheal
injury as a sequence of multiple
attempts of endotracheal intubation in
the course of a preclinical
cardiopulmonary resuscitation.
Resuscitation 43:147–150
11. Kardiopulmonale Reanimation—
Aktuelle Leitlinien des European
Resuscitation Council (2006) Notfall-
und Rettungsmedizin 9:4–170
to avoid these traumas if possible and to be able to dis-
tinguish them from injuries of other origin.
Acknowledgments This work was supported by the State Institute
of Legal and Social Medicine, Berlin/Germany (Director: Prof. M.
Tsokos, MD).
12. Klintschar M, Darok M, Radner H
(1998) Massive injury to the heart after
attempted active compression–
decompression cardiopulmonary
resuscitation. Int J Legal Med 111:93–
96
13. Kurkciyan I, Meron G, Sterz F, Müllner
M, Tobler K, Domanovits H, Schreiber
W, Bankl HC, Laggner AN (2003)
Major bleeding complications after
cardiopulmonary resuscitation: impact
of thrombolytic treatment. J Int Med
253:128–135
14. Krause S, Donen N (1984) Gastric
rupture during cardiopulmonary
resuscitation. Can Anaesth Soc J
31:319–322
15. Krischer JP, Fine EG, Davis JH, Nagel
EL (1987) Complications of cardiac
resuscitation. Chest 92:287–291
16. Larsen R (2002) Kardiopulmonale
Reanimation. In: Larsen R (ed)
Anästhesie, 8th edn. Urban and Fischer
Publishing House, München Jena, pp
851–900
17. Lawes EG, Baskett PJ (1987)
Pulmonary aspiration during
unsuccessful cardiopulmonary
resuscitation. Intensive Care Med
13:379–382
18. Lederer W, Mair D, Rabl W, Baubin M
(2004) Frequency of rib and sternum
fractures associated with out-of-hospital
cardiopulmonary resuscitation is
underestimated by conventional chest
X-ray. Resuscitation 60:157–162
19. Maxeiner H (1988)
Weichteilverletzungen am Kehlkopf bei
notfallmäßiger Intubation. Anästh
Intensivmed 29:42–49
20. Meron G, Kurkciyan I, Sterz F, Susani
M, Domanovits H, Tobler K,
Bohdjalian A, Laggner AN (2007)
Cardiopulmonary resuscitation-
associated major liver injury.
Resuscitation. doi:
10.1016/j.resuscitation.2007.05.023
21. Mills SA, Paulson D, Scott SM, Sethi G
(1983) Tension pneumoperitoneum and
gastric rupture following
cardiopulmonary resuscitation. Ann
Emerg Med 12:94–95
403
22. Minor RL Jr, Chandran PK, Williams
CL (1990) Rhabdomyolysis and
myoglobinuric renal failure following
cardioversion and CPR for acute MI.
Chest 97:485–486
23. Noffsinger AE, Blisard KS, Balko MG
(1991) Cardiac laceration and
pericardial tamponade due to
cardiopulmonary resuscitation after
myocardial infarction. J Forensic Sci
36:1760–1764
24. Odom A, Christ E, Kerr N, Byrd K,
Cochran J, Barr F, Bugnitz M, Ring JC,
Storgion S, Walling R, Stidham G,
Quasney MW (1997) Prevalence of
retinal hemorrhages in pediatric patients
after in-hospital cardiopulmonary
resuscitation: a prospective study.
Pediatrics. doi:10.1542/peds.99.6.e3
25. Price EA, Rush LR, Perper JA, Bell MD
(2000) Cardiopulmonary resuscitation-
related injuries and homicidal blunt
abdominal trauma in children. Am J
Forensic Med Pathol 21:307–310
26. Rabl W, Baubin M, Haid C, Pfeiffer KP
R, Scheithauer R (1997) Review of
active compression–decompression
cardiopulmonary resuscitation (ACD-
CPR). Analysis of iatrogenic
complications and their biomechanical
explanation. Forensic Sci Int 89:175–
183
27. Reichardt JA, Casey GD, Krywko D
(2008) Gastric rupture from
cardiopulmonary resuscitation or
seizure activity? a case report. J Emerg
Med. doi:
10.1016/j.jemermed.2007.10.041
28. Ryan MP, Young SJ, Wells DL (2003)
Do resuscitation attempts in children
who die, cause injury? Emerg Med J
20:10–12
29. Saternus KS, Fuchs V (1982)
Verletzungen der A. carotis communis
durch Reanimationsmaßnahmen. Z
Rechtsmed 88:305–311
30. Schvadron E, Moses Y, Weissberg D
(1996) Gastric rupture complicating
inadvertent intubation of the esophagus.
Can J Surg 39:487–489
31. Shulman D, Beilin B, Olshwang D
(1987) Pulmonary barotrauma during
cardiopulmonary resuscitation.
Resuscitation 15:201–207
404
32. Sokolove PE, Willis-Shore J, Panacek 35. Umach P, Unterdorfer H (1980)
EA (2002) Exsanguination due to right
ventricular rupture during closed-chest
cardiopulmonary resuscitation. J Emerg
Med 23:161–164
33. Sperry K (1990) Anterior thoracic wall
trauma in elderly homicide victims. The
‘‘CPR’’ defense. Am J Forensic Med
Pathol 11:50–55
34. Strear CM, Jarnagin WR, Schecter W,
Mackersie RC, Hickey MS (1998)
Gastric rupture and tension
pneumoperitoneum complicating
cardiopulmonary resuscitation: case
report. J Trauma 44:930–932
Organverletzungen durch
Reanimationsmaßnahmen. Beiträge zur
Gerichtlichen Medizin 38:29–32
36. Valenzuela TD, Kern KB, Clark LL,
Berg RA, Berg MD, Berg DD, Hilwig
RW, Otto CW, Newburn D, Ewy GA
(2005) Interruptions of chest
compressions during emergency
medical systems resuscitation.
Circulation 112:1259–1265
37. van der Voort DJ, Geusens PP, Dinant
GJ (2001) Risk factors for osteoporosis 40. Ziegenfuss MD, Mullany DV (2004)
related to their outcome: fractures.
Osteoporos Int 12:630–638
38. Wik L, Kramer-Johansen J, Myklebust
H, Sørebø H, Svensson L, Fellows B,
Steen PA (2005) Quality of
cardiopulmonary resuscitation during
out-of-hospital cardiac arrest. JAMA
293:299–304
39. Yamaki T, Ando S, Ohta K, Kubota T,
Kawasaki K, Hirama M (1989) CT
demonstration of massive cerebral air
embolism from pulmonary barotraumas
due to cardiopulmonary resuscitation.
J Comput Assist Tomogr 13:313–315
Traumatic liver injury complicating
cardio-pulmonary resuscitation. The
value of a major intensive care facility:
a report of two cases. Crit Care Resusc
2:102–104